Trends in prescription pain management among us adults with arthritis or back pain, 1999-2014

Purpose: Joint and back pain are now among the most common reasons for outpatient medical visits. Use of prescription opioids has increased rapidly over the last two decades. Despite increased attention to the public health consequences of prescription opioid use, evidence is lacking on the distribution and trends by population subgroup in prescription pain management among individuals experiencing chronic arthritis or back pain.

Methods: In this study, we used data from the National Health and Nutrition Examination Survey (NHANES) over the period 1999-2014 to examine trends and sociodemographic patterns in prescription pain management among individuals with arthritis or back pain. We included adult participants aged 30-74 years who reported functional difficulties related to back/neck problems and/or arthritis/rheumatism. Prescription pain management was classified into opioid use; use of a non-narcotic analgesic (e.g., NSAIDs, acetaminophen); use of another pain-related prescription including antidepressants, anxiolytics, muscle relaxants, or anticonvulsants; or no prescription pain management. The prevalence of each category of prescription pain management for the most recent survey wave (2013-2014, n=740) was calculated for the total sample and across subgroups defined by sociodemographic characteristics. Using pooled data from 1999-2014 (n=4,898), we investigated predictors of prescription pain management using multinomial logistic regression using the 4-level outcome (no prescription pain management, other prescription use, non-narcotic analgesic use, opioid use). Predicted probabilities of opioid use for each NHANES survey year were calculated through marginal standardization using the coefficients produced by fully adjusted regression models. These estimates were used to investigate secular trends in prescription opioid use overall and by sociodemographic characteristics.

Results: In 2013-2014, 24.5% (95% CI: 18.3-34.1) of adults aged 30-74 years with arthritis or back pain used prescription opioids, while 16.8% (95% CI: 13.3-21.1) used non-narcotic analgesics, and 21.4% (95% CI: 16.5-27.2) used an antidepressant, anxiolytic, muscle relaxant, or anticonvulsant (Table 1). The remaining 21.0% (14.6-29.3) of the sample reported no pain-related prescription use. The prevalence of opioid use was higher among adults aged 30-49 years (29.1%) compared to older adults (24.3%), males (27.2%) compared to females (24.2%), and non-Hispanic white adults (26.2%) compared to non-Hispanic black adults (22.5%). Additionally, prescription opioid use in 2013-2014 was higher among adults with less than a high school diploma (32.3%) compared to those with higher education (23.6%) and the unemployed (29.4%) compared the employed (16.2%). Adjusting for covariates, the proportion of prescription opioid use increased significantly from 14.2% in 1999-2000 to 24.4% in 2013-2014 (p-value for trend = <0.001). Over the same time period, non-narcotic analgesic use showed a significant downward trend and other prescription use increased significantly, resulting in an overall significant decrease in adults without any type of prescription pain management (Figure 1). Secular trends in prescription opioid use varied by population subgroup (Table 2). A significant increase in prescription opioid use was observed for adults aged 50-74 while a non-significant decrease was seen for younger adults. Opioid use increased more steeply among men compared to women and among non-Hispanic white adults compared to non-Hispanic black adults. Although opioid use increased significantly across education levels, the absolute increase in prescription opioid use between 1999-2000 and 2013-2014 was 22.7% for adults without a high school degree compared to 5.7% for adults with a high school degree. Opioid use also increased significantly for unemployed adults but not for employed adults.

Conclusions: There were marked changes in prescription pain management among US adults with arthritis or back pain between 1999 and 2014, with significant increases in the use of opioid analgesics and other pain-related medications and significant declines in the use of non-narcotic analgesics. Of note, the marked increase in opioid use between 2003 and 2006 coincided with a decline in non-narcotic analgesic use (i.e., primarily NSAIDs), which may reflect changes in prescribing related to withdrawal of COX-II inhibitors from the market.